Etiology Of Skin Wounds And Ulcers - Wound Care Ceu

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ETIOLOGY OF SKIN WOUNDS AND ULCERS

Wound Care

Noah Carpenter, MD Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon practicing in Brandon, Manitoba. He is known for the development of surgical techniques. He attended the University of Manitoba where he graduated with the B.Sc. in chemistry, completed medical school and did his surgical residency and fellowship at the University and Affiliated Hospitals in Edmonton, Alberta. Dr. Carpenter did an additional fellowship at the University of Edinburgh,

Scotland in Adult Cardiovascular and Thoracic Surgery, and has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Vancouver, British Columbia, Canada and Colorado, Texas, Vancouver, and Los Angeles. He has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

Abstract

Although many types of wounds are easily treated, some require specialized

care in order to resolve or treat the primary cause and to avoid

complications. Health clinicians specializing in wound prevention and

treatment focus on patients with an acute or chronic skin injury, related

disease, and medical treatment. Increasingly, wound care specialists are

adopting a holistic approach to treatment, coordinating efforts between

interdisciplinary team members to ensure that all aspects of a patient's

physical and mental health are met during the acute and long-term phases

of the treatment plan.


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Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

Wound care involves an interdisciplinary health team approach to provide

holistic care for patients with acute or chronic wounds that includes

psychosocial, health prevention and medical interventions. Complete

coordination by collaborating health team members improves wound care

management beginning in acute care and throughout the entire continuum

of care. Current evidence and wound care guidelines emphasize the

importance of adhering to evidence-based wound care protocol and of

actively including the patient in ongoing education to support wound healing.

A neglected focus of clinical education pertains to end-of-life care involving

skin and other organ system failure and the challenges most clinicians face

related to prevention of ulcer formation and skin breakdown.


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Course Purpose

To provide health clinicians a basic understanding of the different phases of

healing in acute and chronic wounds, of the risk factors affecting wound

development and healing, and of the prevention and treatment of wounds.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures Noah Carpenter, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


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1. Tertiary intention involves the process of

a. wound closure done by applying physical measures to close a wound.

b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new

granulation tissue to fill in the wound base. d. None of the above

2. When a clinician administers medications intravenously, he or she

should be aware that

a. vesicants are safe because these medications do not cause tissue damage to the skin.

b. it is preferable to administer medications intravenously so they may infiltrate the skin tissues.

c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues.

d. extravasation does not develop if medications are administered intravenously.

3. The National Pressure Ulcer Advisory Panel (NPUAP) has defined

several classifications of pressure ulcers according to the

a. length of tissue involvement and presence of exudate. b. depth of tissue involvement and the extent of damage. c. circumference of tissue involvement and level of pain. d. world health criteria.

4. The dermis is thicker than the epidermis and

a. it is involved in the wound healing process but not scar formation. b. it is the upper levels that contain collagen fibers. c. is not as tough as the epidermis because of its many structures. d. mostly consists of connective tissue.

5. A patient in an intensive care unit may be at higher risk of

pressure ulcers and this is more likely due to

a. a chronic disability. b. a patient’s advanced age. c. language barriers. d. an illness that has caused the patient to be immobile.


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Introduction

Wounds can develop through a number of causes, such as chronic disease,

trauma, cancer, or through surgical procedures. Clinical specialists who care

for patients with skin injuries and varied types of acute or chronic wounds

require thorough knowledge of the skin and its potential for breakdown and

ulceration. When treating a wound, health clinicians manage multiple factors

influencing skin care outcomes, including an underlying disease condition,

medication administration, rehabilitation therapy, and patient education to

promote wound healing and skin health.

Etiology of Wound Development

Multiple causes of skin wounds exist. Known as the largest body organ, skin

provides a significant amount of protection from damaging pathogens and

environmental factors that can cause internal organ injuries. When the skin

breaks down, its damaged areas are unable to function normally. Skin

wounds require time and extra care for healing, particularly when the wound

is deep or extensive.

Skin Injuries

Injuries to the skin surface may result in various types of wounds, from

small and minor tears in the skin to large openings that expose underlying

tissue and organs. The mechanism of injury determines the extent of the

wound, and could include incisions, lacerations, abrasions, bites, penetrating

wounds, and burns.1,8

Wound care can occur at different stages of healing. Initial management of

wounds involves assessment of the injured area (size and depth) and

understanding the mechanism of injury. The health clinician would want to


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ensure no other factors exist that could complicate the wound, such as the

presence of foreign objects or other injuries around the wound. An important

aspect of wound care involves managing the patient’s pain, and preventing

other complications associated with the wound, such as bleeding or

infection.1,8,9

Chronic Disease

Chronic disease can impair skin and tissue integrity, causing wounds that

may be slow to heal. Certain diseases impact the circulatory system, which

causes skin breakdown when the peripheral tissues do not receive enough

oxygen. Examples of diseases that can cause wounds include venous

insufficiency and diabetes.

Skin breakdown after exposure to substances or environmental stimuli can

cause wounds and can impact a person’s mobility and activity levels. There

is also a risk of skin breakdown from pressure sores and poor circulation.

Some diseases can cause an internal growth within the body that may

develop into an external wound. An example would be a cancerous tumor

underneath the skin that grows and results in a skin surface wound, known

as a fungating wound.68,69 When treating a wound caused by a disease

process, a significant part of treatment includes management of the

underlying disease. This may involve administering medications, therapy,

and educating patients about treatment of their health condition.

When a wound has developed as a result of a disease, clinicians need to

assist patients to control symptoms and to prevent recurrence of the wound

in the future.1,8,9


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Medical and Surgical Treatment

Surgical incisions are one of the most common types of wounds that occur,

although other procedures, such as radiation therapy or the administration

of certain kinds of medications, can also cause sores or burns on the skin

that must be monitored and treated.1,9 The process of wound healing may

vary depending on the method of intention used to close the wound. There

are three different stages of intention for wound healing based on the type

of wound, the amount of debris present, whether the wound is

contaminated, and the mechanisms that caused the wound.1,3

Primary Intention

Primary intention is a method of wound closure that is done by applying

physical measures to close a wound. A wound may be closed by primary

intention by applying sutures, staples, or medical-grade glue to approximate

the wound edges and bring them together for healing. Primary intention is

most often used with linear wounds, such as when closing a surgical incision.

As the wound edges grow together to form a scar, the resulting tissue is

typically as strong as the surrounding, undamaged tissue.

Secondary Intention

Secondary intention involves leaving a wound open to heal through the

development of new granulation tissue to fill in the wound base. Eventually,

the wound edges will heal and result in a scar, although this process

typically takes months longer than a wound healed by primary intention.

When the wound has completely healed, the scar tissue covering the wound

is not as strong as the surrounding tissue, and reaches approximately 80

percent of its previous strength as the surrounding, undamaged tissue once


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the wound has healed by secondary intention.3 Examples of wounds that

may heal by secondary intention include wounds that develop from pressure

ulcers, venous ulcers, and diabetic ulcers.

Tertiary Intention

Tertiary intention involves the process of initially leaving the wound open to

partial healing. The application of sutures, staples, or glue, brings the wound

edges together and closes the wound over time. These types of wounds

initially develop some scar tissue as they heal. After the wound edges are

brought together, the scar may become stronger than when the wound was

healing through secondary intention. Tertiary intention may be performed in

a case of an extensive wound that is contaminated and needs to be cleaned

and debrided for a period before surgically closing the wound.3

As a wound heals, it goes through a series of stages in which the tissue that

was broken down comes back together to form a scar. A wound that is small

may heal relatively quickly and without complications. Alternatively, a very

deep wound, one that is contaminated, or a wound in a patient who has an

underlying chronic disease that is poorly controlled, may take much longer

to heal. The phases of wound healing are further explained next.3

Inflammatory Phase

Bleeding that initially occurs will stop when the blood starts to clot. As the

blood clots dry, they form a scab, which is a combination of old blood and

wound exudate. The body’s immune system responds to the wound by

causing inflammation. In the first hours or days after the wound has

developed, it may become red, swollen, and tender to the touch.


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White blood cells are sent to the wound site and there is increased blood

flow to provide oxygen. There may be exudate production at this stage.1,3

Proliferative Phase

Granulation tissue begins to form in the wound bed and angiogenesis, the

process of creating new blood vessels, takes place under the skin. The

wound edges begin to come together as the cells migrate during

epithelialization. This stage lasts anywhere from a few days to several weeks

after the wound has developed.1,3

Remodeling Phase

Collagen formation builds strength in the wound bed; the wound fills in with

epithelial tissue, although it is not as strong as the surrounding tissue. The

remodeling phase may occur for months or years after a wound has

developed.1,3

Wound Types

Wounds are typically classified as being either chronic or acute wounds,

depending on how the wound has formed and the mechanism of injury

causing the wound. Chronic wounds are those that develop after tissue

damage has been ongoing. Examples of chronic wounds include wounds that

develop due to arterial insufficiency, diabetic ulcers, pressure sores, and

wounds that occur from venous insufficiency. The period of time that it takes

to develop a chronic wound may be weeks to months, but the point that

differentiates chronic wounds from acute wounds is that chronic wounds

develop over some period of time.1,3,9


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Alternatively, acute wounds are those that occur after injury to the skin

leads to damage and bleeding. Examples of types of acute wounds include

wounds from burns or trauma, and surgical wounds in which an incision is

made and the surgeon closes the wound with sutures or staples. The type of

wound that occurs, whether it is acute or chronic, typically affects one or

more layers of the skin, and may extend enough to impact the subcutaneous

fat, underlying tendons and ligaments, or may even affect the bones and

organs under the skin.1,3,9,60

The outermost layer of skin, the epidermis, consists of layers of cells that

are continuously pushed upward toward the skin surface where they are

eventually sloughed from the body. The lowest layer of the epidermis is a

row of cells known as germinative cells; these cells divide continuously to

form keratinocytes, which are the cells that make up a majority of the

epidermis. Keratinocytes form from the germinative layer of cells and then

slowly proceed toward the outside edge of the epidermis. As they move,

they become filled with keratin, which is a fibrous protein that provides

structure. Once the keratinocytes reach the outermost layer of the

epidermis, they die. They are not removed immediately, but instead remain

as the surface of the skin where they provide protection against

environmental components that could otherwise invade the body.1,3,9,60

When a wound occurs, part of the healing process involves producing new

skin cells from the germinative cells of the epidermis that are near the

wound edges. The epidermis is a very thin outer layer and covers the lower

dermal layer. Because it is so thin, the epidermis does not contain hair

follicles, blood vessels, or sweat glands, although hairs will protrude from

where they are formed in the dermis and extend through the epidermis to

the skin surface. When a wound occurs that is very superficial and only


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affects the epidermis, the wound typically heals quickly and with little

scarring, as the body is able to produce new skin cells from nearby

germinative cells.

Deeper wounds may affect the dermis, the skin layer that lies below the

epidermis. The dermis is thicker than the epidermis and it mostly consists of

connective tissue. The dermal layer contains many structures, including

blood vessels, hair follicles and nerve endings, as well as other cells that

take part in inflammatory processes when a wound occurs. The dermis is

much tougher than the epidermis because of its composition. The lower

levels of this layer contain collagen fibers that provide strength for the skin

and that take part in wound healing and scar formation.1,3,9,60

Below the dermis is the subcutaneous tissue, which consists of fat and other

components, including blood vessels, nerves, and lymph channels. The

subcutaneous tissue is covered by fascia, a membrane of connective tissue

that provides protection. The subcutaneous tissue covers underlying

structures such as bone and muscle, however, the thickness of

subcutaneous tissue layers varies between locations. Some areas, such as

those of the abdomen or upper thigh, naturally contain more fat tissue when

compared to other areas. The organs and muscles underneath the

subcutaneous tissue also have their own protective membranes. Depending

on the wound and the mechanism of injury, the wound can extend down into

the subcutaneous tissue and can expose underlying muscles or bone.1,3,9,60

There are many different mechanisms that can produce wounds, whether by

disease processes, through acute injury to the tissue, or through ongoing

factors that contribute to skin breakdown over time.


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Pressure Ulcers

A pressure ulcer develops in an area that becomes ischemic because

increased pressure on the skin and underlying tissue prevents adequate

blood flow to the area. Pressure ulcers can develop almost anywhere on the

body where excessive pressure impairs blood flow, but they are most

common on areas that cover bony prominences. The most likely areas where

pressure ulcers develop include the sacrum, the heels, the ear, and the

coccyx.3 Pressure ulcers were once referred to as decubitus ulcers or

bedsores; however, these terms do not necessarily reflect a comprehensive

mechanism of injury. For instance, a person who is not confined to bed may

still develop a pressure ulcer. The term pressure ulcer is more consistent in

defining the means of injury that occurs with this type of wound.9,25

Increased pressure over an area of skin causes compression of the blood

vessels that normally supply oxygenated blood to the skin, subcutaneous

tissue, and underlying fascia. When the blood vessels are constricted in this

manner, blood flow to these areas will slow and the distal areas will not

receive adequate oxygen or nutrients required to maintain healthy skin.9,25

Further, venous return is also slowed, and blood is unable to adequately flow

away from these areas and back toward the heart because of vessel

compression. As a result, metabolic wastes, which are normally carried away

from the area as part of venous return, instead accumulate in the affected

area. This causes a negative cycle as the increased buildup of metabolic

wastes causes vasodilation of surrounding blood vessels, followed by edema,

and further compression of the blood vessels supplying the area.

After a period of time in which blood flow is restricted, tissue ischemia

develops whereby the tissues fed by the compressed blood vessels no longer

have enough oxygen to survive and cell death occurs.9 This cell death then


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contributes to skin breakdown and the affected person develops a pressure

ulcer.

Regular wound assessment is required to determine the depth and extent of

the wound, as well as whether treatment measures are being effective in

healing the wound. The clinician should note the location, size, and

appearance of the wound to better determine the degree of damage. The

National Pressure Ulcer Advisory Panel (NPUAP) has defined several

classifications of pressure ulcers according to the depth of tissue

involvement and the extent of damage.78 By understanding the stages of

pressure ulcers, the clinician can assess a wound and better understand how

it is staged. By staging the wound, the clinician then has a guide for the best

form of wound management.1,3,8,78

Stage I

In stage I the skin is still intact but does not blanch when pressed. The skin

appears red, which does not resolve with time or position changes. It may

more likely appear over a bony prominence. In a person with dark skin, the

area may not be red or even noticeable except that the affected skin

appears as a different color when compared to the surrounding skin.

Normally, an area of skin may turn red after a short period of pressure; this

situation is known as reactive hyperemia. The process occurs when the body

increases blood flow to the compressed area to make up for temporary

oxygen deprivation. With reactive hyperemia, the skin becomes red and

appears flushed; however, this typically resolves quickly with position

changes and as blood flow resumes to its normal pattern.


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An area of redness can be considered a stage I ulcer if the redness does not

resolve and the area does not blanch.

Stage II

The skin is broken in Stage II but the wound is typically confined to the

epidermis. The skin appears red and blisters, filled with serous fluid. Blisters

may have broken, resulting in shallow wounds that ooze. The base of the

wound may appear pink or red and slough may or may not be present.

Stage III

In stage III the wound is deep enough that it extends through the epidermis

and into the dermis. A stage III pressure wound is considered a full-

thickness wound; however, this stage of wound does not affect the

underlying muscle, tendons, or bone. The subcutaneous fat under the dermis

may be seen in some areas where there are greater amounts of fat. Slough

may or may not be present at the base of the wound, which may make it

difficult to determine depth. Stage III wounds can have tunneling, in which a

hole or tunnel progresses deeper into surrounding tissue. If a second wound

is nearby, tunneling may connect the two wounds.

Undermining may also be present at stage III, which occurs when the edges

of the wound at the surface cover more of the wound than is present at the

base. When undermining is present, the wound is actually larger than it

appears at the surface.

Stage IV

Stage IV pressure ulcer is a full-thickness wound that extends from the

epidermis into the dermis and subcutaneous tissue and exposes underlying


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bones, muscles, or tendons. In areas where there is less subcutaneous fat

and cartilage is present instead, such as on the nose or the ear, the

exposure of underlying cartilage classifies the wound as a stage IV pressure

ulcer. Tunneling and undermining may also be present with this stage of

wound.

In addition to the standard categories of wounds based on the depth of the

affected tissue and the exposure of underlying structures, there are other

classifications of pressure wounds that account for injuries with

measurements or depth that are not obvious and apparent.1-4,9,78

Unstageable Wound

The unstageable type of wound is not obvious as far as its depth is

concerned. The clinician may not be able to classify the wound based on its

appearance and further measurements are often required. The base of the

wound is usually covered with slough or eschar, which makes the depth of

the wound difficult to determine.

Several other terms that describe wound tissue may be identified as

characteristics of wounds; these elements may be present in pressure ulcers

or in wounds that have developed as a result of other reasons. Eschar is

used to describe necrotic tissue that has developed within a wound. Eschar

is dead skin that is often tough and thick; it may have a similar appearance

to a scab but it is not the same. Eschar is what must be removed with

debridement. Without removal of eschar, would healing can be significantly

delayed.

Slough is another component of the wound that may develop alongside

eschar, but it has an appearance that is different. Slough is also a collection


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of necrotic tissue, but unlike eschar, it is typically moist, crusty, or crumbly.

It is typically white, yellow, or cream colored and it is thought to contain

dead leukocytes, bacteria, dead skin, fibrin, and wound exudate. Slough

must be removed during debridement in order to promote wound healing, as

the body typically cannot get rid of slough on its own and it may accumulate,

harboring bacteria and preventing growth of normal, new skin tissue.

Deep Tissue Injury

In a deep tissue injury (DTI) the skin may or may not be broken but there is

significant bruising that appears as blue or purplish skin with bruising that

extends down into lower layers of skin. The appearance of the wound may

also look like that of a blood-filled blister. The texture of the skin with a DTI

can vary; some patients have skin that feels warmer than surrounding

tissue, while others have cooler skin. The skin texture may feel firm or it

may be mushy. Some patients have intense pain while others do not.

Deep tissue injury occurs in an area that has been injured by shear forces. It

can be difficult to determine how deep the injury is and if it extends down

past the dermal layer. A DTI can be difficult to assess in a patient with dark

skin. As the injury heals, it may become an ulcer with open skin on the

surface or it may resolve under the skin.

Kennedy Terminal Ulcer

The Kennedy Terminal Ulcer is a specific type of skin breakdown that may

occur hours, weeks, or months before death in a terminal patient. This type

of terminal ulcer typically develops among patients who are nearing death

and placed in a long-term care setting. The skin takes on a purple, red, or

yellow appearance and the wound may be shaped like a pear or a butterfly.

The most common location where the ulcer develops is on the sacrum,


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although it can show up on any part of the skin. This type of ulcer may be

more commonly seen by clinicians caring for patients in a long-term care

facility or among those who work in Critical Care Units (CCUs) that may

receive patient transfers from long-term care facilities.

A Kennedy terminal ulcer may develop rapidly through the process of skin

breakdown as the patient nears death. As a person nears death, organ

failure is often a cause of death. The skin, the largest organ of the body,

may also fail, leading to skin breakdown associated with a Kennedy terminal

ulcer.

Factors Contributing to Pressure Ulcers

Other factors may contribute to the development of pressure ulcers, placing

certain patients at higher risk. Immobility is a primary cause of pressure

ulcer development, as the inability to move or change positions to relieve

pressure on an affected area results in compressed blood vessels over time.

Patients who have excess skin moisture due to sweating or poor hygiene are

at increased risk, particularly when the skin becomes ischemic from too

much pressure. The excess moisture on the skin causes the surface skin to

become softer and more prone to breakdown.5,9

Older adults are a population at high risk, not only because of their

increased instances of immobility, but also because of body changes

associated with aging. Many older adults have less subcutaneous fat under

the surface of the skin, which results in less protection from epidermal

injury.9,25 Older adults also have thinner skin as a result of aging, which

often becomes dry and less elastic due to decreased action of collagen and

elastin within the skin’s structure. These effects of aging cause the skin to

heal much more slowly when a wound occurs. Further, some older adults


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suffer from sensory changes that result in diminished sensation in the

extremities and distal tissues. These older adults may be less likely to

perceive when tissue damage is happening because they cannot feel it

immediately.

Obese patients are also at higher risk of skin breakdown due to pressure

ulcers and tissue ischemia. Patients who are obese have more weight

applied to certain areas when lying in different positions. A person who is

obese may have extra skin folds that can retain moisture and can be difficult

to clean. The skin in these folds may break down more easily when moisture

remains between the folds or when skin folds rub on bed sheets or linens,

causing small abrasions on the surface of the skin.

Various intrinsic and extrinsic factors can impact the risk of developing

pressure ulcers.78 Intrinsic factors that affect wound development include

age, circulation status, personal habits that affect skin integrity (smoking,

diet, alcohol consumption), body temperature, use of some medications

(steroids, vasoactive drugs), weight, and history of injury or disability. Some

intrinsic factors can be changed, while others cannot. Extrinsic factors

include such elements as friction and shear, level of moisture, irritating

substances on the skin, and the environment that prevents movement or

turning to relieve pressure.

Assessment Tools and Rating Scales

Multiple rating scales are available to assess patient risk for the development

of pressure ulcers. In the U.S., the Braden scale is one of the most common

tools used to assess whether particular patients are at risk of skin

breakdown or if the skin is no longer intact. The clinician may use the

Braden scale when performing a patient assessment.78 The results are given


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scores based on factors such as the patient’s level of sensory perception,

moisture content of the skin, nutrition levels, and mobility. The lower the

Braden scale score the higher the risk for skin breakdown.

Assessment tools may be used on any patient who may be at risk of

pressure ulcers. Although not all patients may need intervention for pressure

ulcer prevention, it is always better to provide more care to prevent ulcers

than to avoid interventions because a patient is believed to be at low risk.

Increased clinical interventions for prevention of pressure ulcers has been

shown to decrease pressure ulcer development regardless of the patient’s

level of risk.

Arterial Insufficiency

Arterial insufficiency refers to decreased and inadequate blood flow to

tissues and organs. A patient with arterial insufficiency is at increased risk of

developing ulcers when the skin and underlying tissue lacks healthy blood

flow and becomes ischemic. Arterial insufficiency ulcers most commonly

affect the lower extremities, including the legs and feet.10 As blood flow

diminishes, the cells are starved for oxygen and tissue ischemia develops.

Without correction of adequate blood flow, the skin becomes necrotic and

starts to break down, forming a wound.

Arterial insufficiency can develop through various causes and it may occur

suddenly or it can develop gradually. A sudden cause of arterial insufficiency

may result from trauma or injury to a part of the body that disrupts blood

flow to the extremities. Alternatively, chronic arterial insufficiency may

develop over time due to atherosclerosis.9,10


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Several conditions are associated with arterial insufficiency and patients with

these illnesses are more likely to suffer from blood flow abnormalities and

wounds that develop from arterial insufficiency. Examples include

thrombosis of any cause, vasculitis, rheumatoid arthritis, systemic lupus

erythematosus, sickle cell disease, polycythemia, and Raynaud’s

phenomenon. These conditions affect blood circulation through such factors

as abnormalities in blood vessel structure or anomalies within blood cells,

resulting in decreased circulation to peripheral tissues. Despite underlying

abnormalities in blood flow associated with certain diseases, the most

common cause of arterial insufficiency is atherosclerosis.9,10

Frequent sites of ulcers in the lower extremity include the lateral malleolus

of the ankle, the foot, and the toes. Wounds that develop from arterial

insufficiency are often small and round without granulation tissue in the

wound base. They often cause significant pain for the affected patient.

Arterial insufficiency causes symptoms similar to that of peripheral arterial

disease (PAD) and is often affiliated with the condition. PAD develops as a

result of atherosclerosis in the large vessels that supply blood to the lower

extremities; the plaques found in the walls of the blood vessels disrupt blood

flow and decrease circulation. Older adults are at increased risk of PAD and,

ultimately, an increased risk of arterial insufficiency wounds. Older adults

are more likely to develop atherosclerosis, as the incidence increases with

advancing age.7-10

When a wound does develop as a result of decreased blood flow, the healing

process can be slow and difficult. Because oxygen is needed not only to

prevent wounds from forming, but also for wounds to heal properly,

decreased oxygenation from arterial insufficiency results in wounds that heal


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poorly and that do not close properly. When a wound develops because of

trauma, the wound is more likely to close slowly and have difficulties with

healing in a person with arterial insufficiency when compared to someone

with normal circulation. For example, a person with PAD if injured by

stepping on a sharp object may have a wound at the site of the injury.

Decreased circulation to the site may further potentiate spreading of the

wound or it may limit the pace at which the wound heals.

Arterial insufficiency often is paired with other illnesses that all contribute to

wounds and ulcers as a result of impaired circulation. A patient may not only

have arterial insufficiency due to peripheral artery disease or vasculitis, but

may also have other conditions that contribute to wound development, such

as diabetes.8-10 The risk of ulceration and tissue necrosis is often increased

when more than one condition affecting circulation is present.

Wound Risk Factors

Although there are various causes of wounds that result from differing states

of health or disease, there are some risk factors that are more common to

wound development in general. By and large, a poor state of health, whether

because of chronic disease, malnutrition, lack of activity, or poor self-care,

typically contributes to an increased risk of wound development and poor

wound healing when a wound does happen.

Insufficient Oxygen

Poor oxygen perfusion contributes to wound development when the tissues

do not receive enough oxygenated blood. This may more likely occur in a

condition in which blood flow is reduced or blocked due to an occlusion, such

as in the case of arterial insufficiency or peripheral arterial occlusive disease.


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The skin and underlying tissues need oxygen from the blood in order to stay

healthy and to prevent the growth of anaerobic bacteria, which are

microorganisms that can grow in the absence of oxygen. When the skin and

peripheral tissues do not have enough oxygen, the skin is more likely to

break down, causing a wound, and the resultant wound could become

infected more easily.1,12,13

Malnutrition

Malnutrition impacts wound healing due to changes in protein sufficiency and

lack of vitamins that normally act as healing factors in the body. Malnutrition

can develop in some people because of a lack of intake due to a number of

situations, including socioeconomic factors that affect accessibility of food,

stressful events or periods of severe illness, difficulties with feeding,

chewing, or swallowing food, malabsorption syndromes that affect how the

body digests and absorbs nutrients, or mental health diagnoses of eating

disorders, such as anorexia.1,9,54 Alternatively, malnutrition can also occur

among some patients who are overweight or obese. An obese patient may

have malnutrition even when food intake is excessive because he or she may

only be eating certain types of foods that add to weight gain but that do not

provide important nutrients.

When a person is malnourished, protein is used for energy instead of

glucose. To get this protein, the body breaks down its own sources, such as

protein found within skeletal muscle tissue. Because wound healing requires

protein to form a healing matrix through collagen, wounds may heal slower

when the body is focusing its protein sources instead on gaining energy.54

Malnutrition also contributes to wound development through other methods.

Poor nutrition depletes lean body mass and the patient has less muscle


23

tissue for activities of daily living; he or she may be more likely to develop

greater degrees of immobility, which can further impair other body

processes and contribute to skin breakdown. Further, decreased protein

intake impairs the immune system and can increase the risk of infection if a

wound develops.8,54

A patient who develops an illness or goes through a surgical procedure loses

a certain amount of protein each day. This protein loss then contributes to

further effects that can lead to wound development. Additionally, certain

procedures, periods of hospitalization, or general lack of intake can affect

how well a wound heals when it does develop.53 Malnutrition has been shown

to impact function of both B and T lymphocytes and prevents proper

functioning of leukocytes in the body, increasing the risk of infection.

Further, if a wound starts to develop skin breakdown may be perpetuated by

loss of protein and malnutrition; as a malnourished state also increases the

length of the inflammation stage of wound healing, it decreases collagen

synthesis and decreases overall strength of the skin.

A patient who is malnourished may also be underweight and may have less

fat tissue to protect bony prominences. Consequently, more bony

prominences increase the risk of pressure ulcers without the extra padding

under the skin. A patient who has decreased muscle mass and more bony

prominences as a result of malnutrition may have less activity when

compared to another person who is not malnourished.54 The increase in

immobility, decrease in muscle mass, and greater number of pressure points

can all contribute to skin breakdown associated with pressure ulcers.

Diabetes mellitus can cause a form of malnutrition because the patient has

abnormal carbohydrate metabolism and is therefore unable to adequately


24

use this type of macronutrient in a normal manner needed for the body.

Diabetes, or even a severe state of stress or illness that leads to changes in

blood glucose concentrations, can disrupt the functions of the cells of the

immune system, thereby increasing the risk of infection.18,21 Hyperglycemia

has also been shown to reduce the body’s ability to absorb vitamin C into

leukocytes and fibroblasts in the skin cells.

Several vitamins are also necessary to help the body with wound healing.

Vitamin C, or ascorbic acid, is needed for synthesis of collagen, which

provides a structural framework in the growth of new tissue in the wound

bed. Vitamin C also supports the body’s immune response, and lack of

vitamin C may contribute to increased inflammation when a wound has

developed.

Vitamin A deficiency leads to a decrease in the function of certain types of

immune cells, including macrophages and monocytes. Vitamin D depletion

also leads to decreased strength in the healed wound if one does develop.

Another fat-soluble vitamin, vitamin E, is associated with health of the skin.

Deficiencies in vitamin E are uncommon, but they can cause problems with

the body’s defenses because of its antioxidant properties. Further, vitamin E

deficiency may lead to uncontrolled inflammation in and around the wound.

Fluid volume deficit also has an impact on wound healing. A patient may

have adequate intake of food and may gain enough vitamins, minerals, and

nutrients through eating, but lack of fluid can lead to dehydration, which can

stunt the wound healing process. Dehydration causes a decrease in overall

circulation; in addition to causing other problems such as electrolyte

imbalance, decreased blood volume from dehydration prevents adequate

blood flow from reaching the wound site. The body is less able to send blood


25

cells to the site of injury for their part in maintaining immunity, stimulating

wound healing, and preventing infection.

Immobility

Immobility is one of the most common factors associated with pressure ulcer

development, but it also plays a contributing role in wound development for

patients with other chronic diseases, such as venous insufficiency and

diabetes. Lack of movement from immobility decreases overall circulation

and can cause wounds related to incontinence or an inability to perform self-

care measures.1 When a patient is immobile and must rely on caregivers for

movement or repositioning, he or she is at greater risk of skin breakdown

because of an inability to shift positions to take pressure off of certain areas

of the skin. Wounds may be more likely to occur in an immobile patient who

must spend a significant amount of time in bed or sitting in a chair, and who

otherwise can do little to increase circulation in the extremities and support

or maintain proper blood flow.55-57

Many immobile patients have difficulties with getting up to use the bathroom

and are often forced to rely on bedpans, catheters, and/or bedside

commodes for elimination. Immobile patients may be at increased risk of

incontinence if they are unable to access these devices quickly enough or if

they must rely on a caregiver for help.55-57 Urinary and fecal incontinence

contribute to skin breakdown because of the components of these wastes.

Urine is a fluid that, when left on the skin, increases moisture content and

causes skin softening and maceration. The enzymes found in stool, as well

as its pH content can also cause skin breakdown, particularly after times

when fecal matter is left on the skin without being cleaned in a timely

manner.


26

Many people think of immobility as affecting older adults who are living in

long-term care facilities and who are dependent on caregivers for help with

turning or with getting out of bed. While this is true in many cases, another

population of patients are at risk of skin breakdown because of immobility in

the healthcare environment are those who receive care in the intensive care

unit. Patients in intensive care environments are at risk of wound

development, often because of the increased amounts of medical equipment

used because of their fragile medical states.1,3 A patient in the intensive care

unit may be at higher risk of pressure ulcers because he or she is typically

immobile because of illness, rather than a chronic disability or advanced age,

as is seen among some other immobile patients. The patient in the intensive

care unit often also needs more medical equipment as part of his or her

care, which may include a ventilator, urinary catheter, sequential

compression device, intravenous line or central catheter, and hemodynamic

monitoring systems. Some of the medications administered to a patient may

also increase the risk for skin breakdown.

Based on the amount of equipment required and the clinical status of acute

illness, the intensive care unit patient is actually quite immobile. Depending

on the level of care required, he or she may not be able to get up or move

out of bed in any way, whether because of illness and level of consciousness

or because of the presence of so many pieces of medical equipment needed

to provide care. For example, a patient who requires mechanical ventilation

typically requires sedation, which places him or her in an altered state of

consciousness and, most likely, restricted to bed rest rather than chair

activity to facilitate position changes. Prevention of pressure ulcers,

therefore, is centered on turning and repositioning the patient frequently and

preventing medical equipment from applying too much pressure at a

particular site.1,3


27

In addition to limiting how much a patient in the intensive care unit is able

to get up or move, medical equipment also places pressure on certain parts

of the skin, which can lead to skin breakdown. An endotracheal tube that is

positioned in the same area or that presses against the lip for too long can

cause tissue breakdown in that area. A patient who is turned and who is

accidentally positioned so that the catheter hub of the central line is under

the body can suffer from skin breakdown in a short time due to the

intravenous tubing continuously pressing into the skin until such time the

patient is moved again.62,78 The administration of some vesicant solutions as

part of treatment for complex medical conditions often seen in the intensive

care unit can cause significant skin and tissue damage if extravasation

occurs. For instance, administration of cisplatin can cause tissue damage and

necrosis if it leaks from the intravenous site into the surrounding tissue.

Comorbidities

Certain factors impact wound development and affect healing when a wound

does develop. Comorbidities are diseases that are present in the patient that

may directly cause wound development or may result in a wound becoming

chronic and difficult to heal. Some patients have several comorbidities,

making their risks for wound development much higher than the general

population.

As a wound goes through the phases of healing, a comorbid condition that is

already present in the patient may interrupt the process and either slow or

stop wound healing altogether or cause complications that require further

intervention. For example, a patient who has diabetes and has developed a

foot wound may be on track with wound healing through proper care and

wound management.66,67 However, time spent with uncontrolled blood

glucose levels and improper foot care — both of which are factors associated


28

with diabetes as a comorbidity in this case — can lead to a wound infection

and skin breakdown on the wound periphery, further complicating the

healing process.

There are a number of comorbid conditions that can impair and delay wound

healing. These factors may contribute to the cause of the wound or they

may be elements that affect the wound’s healing progress. Examples of

comorbid conditions that can impact wound development and healing include

chronic conditions such as diabetes, vasculitis, systemic lupus

erythematosus, renal failure, various forms of cancer, rheumatoid arthritis,

and scleroderma.66,67

When comorbidities are present in the wound care patient, the health

clinician performs more than one role. Part of wound care management is

controlling the health of the wound, providing supportive care and treatment

through dressing changes and medication administration, and ensuring that

the patient knows how to care for the wound. Additionally, interventions

need to be implemented that address comorbid conditions to prevent

delayed wound healing.

As part of comprehensive care, medical therapy and patient education must

be part of the patient treatment plan to improve health and psychosocial

outcomes.11 As an example, a patient who has renal failure and a lower leg

ulcer not only needs ongoing wound care through assessment and

treatment, but also needs supportive treatment for renal disease. Care of

comorbid conditions will impact wound healing and is a necessary part of

treatment. In addition to providing wound care, medical care and other

interdisciplinary referrals, such as a dietary consult, occupational therapy or

social service support may be needed. In the case of a patient with renal


29

failure, a referral to a nephrologist and possible dialysis would be a

reasonable course of care.

Any patient who has a chronic disease and a healing wound must be

educated about how the condition affects wound repair and healing. Because

the patient should be an active participant in the wound care process, he or

she needs to know what factors could possibly delay wound healing. The

patient may or may not understand the correlation between a chronic

disease and a wound involving the skin.3,11 It is the clinician’s responsibility

to educate the patient about how each condition is related to the other. By

educating the patient about the factors that affect wound healing, the

patient can become more involved in his or her treatment regimens and may

take steps to assist not only with wound care, but with care of his or her

chronic disease as well.11

Medications

Certain medications can cause skin breakdown when they cause changes in

the skin because of side effects or when they are inadvertently administered

in a method that the medication interacts with the skin when it is not

supposed to. There are a number of medications that cause rash or eczema

as side effects. While this may not initially cause skin breakdown, the skin

can become more sensitive when a patient takes medications with these

effects. The patient may also scratch the skin in an attempt to soothe the

itching; excessive scratching can eventually lead to skin breakdown, sores,

or lesions.

Some medications, when administered intravenously, can cause significant

wounds if their solutions are accidentally infiltrated into the skin and tissues.

This can happen when, upon administration of the medication into the


30

intravenous catheter, the medication leaks out into the tissues and causes

damage. Medications known as vesicants can cause tissue damage and

necrosis of the skin when extravasation occurs during administration.

Extravasation can lead to such a significant wound that the patient requires

debridement and regular dressing changes while the wound heals,

sometimes over a period of weeks or months. When a health clinician must

administer medications intravenously, he or she should be aware of the

potential effects on the skin.52,55 When giving vesicant medications, the

clinician must routinely check the intravenous catheter and monitor the

intravenous site and the tubing for changes to ensure that extravasation

does not develop and cause severe tissue damage to the skin.

Summary

Management of wounds involves a number of considerations, which include

the mechanism of injury and the assessment of the wound. Assessment of

the wound involves the wound size and depth. Additionally, it is important to

consider other complicating factors, such as the presence of foreign objects

or other injuries around the wound, pain management, and the prevention

of bleeding or infection.

The process of wound healing may vary depending on the method of

intention used to close the wound. Wounds are healed by intention, which is

categorized into three different stages, primary, secondary and tertiary;

and, is based on the type of wound, the amount of debris present or if the

wound is contaminated, and the mechanisms of the cause of the wound.

Wounds are typically classified as being either chronic or acute wounds.

Chronic wounds are those that develop after tissue damage has been

ongoing, such as, wounds due to arterial insufficiency, diabetic ulcers,

pressure sores, and venous insufficiency. The point that differentiates


31

chronic wounds from acute wounds is that chronic wounds develop over

some period of time.

Risk factors more common to wound development generally include a poor

state of health due to chronic disease or poor self-care. Immobility, the most

common factors associated with pressure ulcer development, also plays a

contributing role in wound development for patients with chronic diseases,

such as venous insufficiency and diabetes. A decrease in overall circulation

due to immobilization can cause wounds related to incontinence or poor self-

care performance. Patients at risk of skin breakdown rely on caregivers to

help with mobility and position change to prevent skin pressure areas.

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32


a. wound closure done by applying physical measures to close a wound.

b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new

granulation tissue to fill in the wound base. d. None of the above



a. vesicants are safe because these medications do not cause tissue damage to the skin.

b. it is preferable to administer medications intravenously so they may infiltrate the skin tissues.

c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues.

d. extravasation does not develop if medications are administered intravenously.



a. length of tissue involvement and presence of exudate. b. depth of tissue involvement and the extent of damage. c. circumference of tissue involvement and level of pain. d. world health criteria.


a. it is involved in the wound healing process but not scar formation. b. it is the upper levels that contain collagen fibers. c. is not as tough as the epidermis because of its many structures. d. mostly consists of connective tissue.



a. a chronic disability. b. a patient’s advanced age. c. language barriers. d. an illness that has caused the patient to be immobile.


33

6. Malnutrition impacts wound healing due to

a. lean body mass (a low BMI). b. the presence of more muscle and less fat tissues. c. changes in protein sufficiency and lack of vitamins. d. autoimmune factors.

7. A patient with a chronic disease and immobility is prone to wound

development due to

a. decreased overall circulation. b. incontinence. c. inability to perform self-care measures. d. All of the above

8. There are three different stages of _____________ for wound

healing based on the type of wound, the amount of debris present, whether the wound is contaminated, and the mechanisms that caused the wound.

a. infection b. closure c. intention d. inflammation

9. Hyperglycemia has also been shown to reduce the body’s ability

to absorb ____________ into leukocytes and fibroblasts in the skin cells.

a. Vitamin C b. Vitamin E c. Vitamin B complexes d. Vitamin A

10. ______________ medication can cause tissue damage and


a. Evacuante b. Vesicant c. Esicant d. Vesic


34

11. Wounds are healed by intention, which is categorized in stages of

a. primary, secondary and tertiary. b. principal and complicating. c. initial trauma and secondary infectious. d. non-infected and infected.

12. Fluid volume deficit can stunt the wound healing process

because

a. decrease in overall circulation. b. electrolyte imbalance. c. decreased blood volume to send blood cells to site of injury. d. All of the above

13. Chronic wounds are those that develop

a. due to arterial and venous insufficiency. b. at the time of injury. c. as a category of wound occurring after 3 days. d. due to electrolyte imbalance.

14. _______________ has been shown to impact function of both B

and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.

a. Dehydration b. Malnutrition c. Acute blood loss d. Blunt trauma

15. Deficiencies in vitamin E

a. are common, and may impact the function of B and T lymphocytes. b. are uncommon, and may lead to uncontrolled wound inflammation. c. are not known to impair the body’s defenses. d. lead to coagulopathy and blood loss.

16. True or False: A severe state of stress or illness that leads to

changes in blood glucose concentrations can disrupt the


35

functions of the cells of the immune system, thereby increasing the risk of infection.

a. True b. False

17. _________________ wounds can have tunneling.

a. Stage I b. Stage II c. Stage III d. All of the above

18. True or False: When undermining is present, the wound is

smaller than it appears at the surface.

a. True b. False

19. Primary intention is most often used with linear wounds, such

as when closing

a. pressure ulcers. b. venous ulcers. c. diabetic ulcers. d. a surgical incision.

20. _________________ is needed for synthesis of collagen, which

provides a structural framework in the growth of new tissue in the wound bed.

a. Vitamin D b. Vitamin E c. Vitamin C d. Vitamin A

CORRECT ANSWERS:


36


b. initially leaving the wound open to partial healing. “Tertiary intention involves the process of initially leaving the wound open to partial healing. The application of sutures, staples, or glue, brings the wound edges together and closes the wound over time. These types of wounds initially develop some scar tissue as they heal.”



c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues. “Some medications, when administered intravenously, can cause significant wounds if their solutions are accidentally infiltrated into the skin and tissues.... Medications known as vesicants can cause tissue damage and necrosis of the skin when extravasation occurs during administration.... When giving vesicant medications, the clinician must routinely check the intravenous catheter and monitor the intravenous site and the tubing for changes to ensure that extravasation does not develop and cause severe tissue damage to the skin.”



b. depth of tissue involvement and the extent of damage. “The National Pressure Ulcer Advisory Panel (NPUAP) has defined several classifications of pressure ulcers according to the depth of tissue involvement and the extent of damage. By understanding the stages of pressure ulcers, the clinician can assess a wound and better understand how it is staged. By staging the wound, the clinician then has a guide for the best form of wound management.”



37

d. mostly consists of connective tissue. “The dermis is thicker than the epidermis and it mostly consists of connective tissue.... The dermis is much tougher than the epidermis because of its composition. The lower levels of this layer contain collagen fibers that provide strength for the skin and that take part in wound healing and scar formation.”



d. an illness that has caused the patient to be immobile. “A patient in the intensive care unit may be at higher risk of pressure ulcers because he or she is typically immobile because of illness, rather than a chronic disability or advanced age, as is seen among some other immobile patients.”

6. Malnutrition impacts wound healing due to

c. changes in protein sufficiency and lack of vitamins. “Malnutrition impacts wound healing due to changes in protein sufficiency and lack of vitamins that normally act as healing factors in the body.”

7. A patient with a chronic disease and immobility is prone to wound

development due to

a. decreased overall circulation. b. incontinence. c. inability to perform self-care measures. d. All of the above [correct answer]

“Immobility is one of the most common factors associated with pressure ulcer development, but it also plays a contributing role in wound development for patients with other chronic diseases, such as venous insufficiency and diabetes. Lack of movement from immobility decreases overall circulation and can cause wounds related to incontinence or an inability to perform self-care measures.”

8. There are three different stages of _____________ for wound

healing based on the type of wound, the amount of debris


38

present, whether the wound is contaminated, and the mechanisms that caused the wound.

c. intention “The process of wound healing may vary depending on the method of intention used to close the wound. There are three different stages of intention for wound healing based on the type of wound, the amount of debris present, whether the wound is contaminated, and the mechanisms that caused the wound.”

9. Hyperglycemia has also been shown to reduce the body’s ability

to absorb ____________ into leukocytes and fibroblasts in the skin cells.

a. Vitamin C “Hyperglycemia has also been shown to reduce the body’s ability to absorb vitamin C into leukocytes and fibroblasts in the skin cells.”

10. ______________ medication can cause tissue damage and


b. Vesicant “Medications known as vesicants can cause tissue damage and necrosis of the skin when extravasation occurs during administration.”

11. Wounds are healed by intention, which is categorized in stages

of

a. primary, secondary and tertiary. “Wounds are healed by intention, which is categorized into three different stages, primary, secondary and tertiary;....”

12. Fluid volume deficit can stunt the wound healing process

because


39

a. decrease in overall circulation. b. electrolyte imbalance. c. decreased blood volume to send blood cells to site of injury. d. All of the above [correct answer]

“Fluid volume deficit ... can lead to dehydration, which can stunt the wound healing process. Dehydration causes a decrease in overall circulation; in addition to causing other problems such as electrolyte imbalance, decreased blood volume from dehydration prevents adequate blood flow from reaching the wound site. The body is less able to send blood cells to the site of injury for their part in maintaining immunity, stimulating wound healing, and preventing infection.”

13. Chronic wounds are those that develop

a. due to arterial and venous insufficiency. “Chronic wounds are those that develop after tissue damage has been ongoing, such as, wounds due to arterial insufficiency, diabetic ulcers, pressure sores, and venous insufficiency.”

14. _______________ has been shown to impact function of both B

and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.

b. Malnutrition “Malnutrition has been shown to impact function of both B and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.”

15. Deficiencies in vitamin E

b. are uncommon, and may lead to uncontrolled wound inflammation. “Deficiencies in vitamin E are uncommon, but they can cause problems with the body’s defenses because of its antioxidant properties. Further, vitamin E deficiency may lead to uncontrolled inflammation in and around the wound.”

16. True or False: A severe state of stress or illness that leads to changes in blood glucose concentrations can disrupt the


40

functions of the cells of the immune system, thereby increasing the risk of infection.

a. True “Diabetes, or even a severe state of stress or illness that leads to changes in blood glucose concentrations, can disrupt the functions of the cells of the immune system, thereby increasing the risk of infection.”

17. _________________ wounds can have tunneling.

c. Stage III “Stage III wounds can have tunneling, in which a hole or tunnel progresses deeper into surrounding tissue. If a second wound is nearby, tunneling may connect the two wounds.”

18. True or False: When undermining is present, the wound is

smaller than it appears at the surface.

b. False “Undermining may also be present at stage III, which occurs when the edges of the wound at the surface cover more of the wound than is present at the base. When undermining is present, the wound is actually larger than it appears at the surface.”

19. Primary intention is most often used with linear wounds, such

as when closing

d. a surgical incision. “Primary intention is most often used with linear wounds, such as when closing a surgical incision.”

20. _________________ is needed for synthesis of collagen, which

provides a structural framework in the growth of new tissue in the wound bed.


41

c. Vitamin C “Several vitamins are also necessary to help the body with wound healing. Vitamin C, or ascorbic acid, is needed for synthesis of collagen, which provides a structural framework in the growth of new tissue in the wound bed.”

References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [References are for a multi-part series on WOUND CARE].

1. Armstrong, D. and Meyr, A. (2017). Basic principles of wound management. UpToDate. Retrieved online at https://www.uptodate.com/contents/basic-principles-of-wound-management.

2. Brown, MS, Ashley, B. and Koh, A. (2018). Wearable Technology for Chronic Wound Monitoring: Current Dressings, Advancements, and Future Prospects. Front Bioeng Biotechnol. 2018 Apr 26;6:47.

3. Armstrong, D. and Meyr, A. (2018). Basic principles of wound healing. UpToDate. Retrieved from https://www.uptodate.com/contents/basic-principles-of-wound-healing?search=wound%20healing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

4. Falconio-West, M. (2013). Kennedy Terminal Ulcer (KTU) is now recognized by CMS for long-term acute care hospitals (LTAC or LTCH). Retrieved from http://mkt.medline.com/clinical-blog/channels/clinical-solutions/kennedy-terminal-ulcer-ktu-is-now-recognized-by-cms-for-long-term-acute-care-hospitals-ltac-or-ltch/

5. Medtronic (2016). PRESSURE ULCER PREVENTION: ADVANCED PATIENT MONITORING TECHNOLOGY FOR REPOSITIONING MANAGEMENT. Medtronic/Covidien. Retrieved from http://www.covidien.com/imageServer.aspx/doc340207.pdf?contentID=83123&contenttype=application/pdf.

6. Mishra, SC., et al. (2017). Diabetic Foot. BMJ. 2017 Nov 16;359:j5064. 7. Checklist for factors affecting wound healing. Adv Skin Wound Care.

2011 Apr;24(4):192.


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8. Zakhary, SA, et al. (2017). The Development and Content Validation of a Multidisciplinary, Evidence-based Wound Infection Prevention and Treatment Guideline. Ostomy Wound Manage. 2017. Nov;63(11):18-29.

9. Berlowitz, D. (2018). Clinical staging and management of pressure-induced skin and soft tissue injury. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-staging-and-management-of-pressure-induced-skin-and-soft-tissue-injury?search=pressure%20ulcers&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

10. Peterson, M.J. (2018). Approach to the differential diagnosis of leg ulcers. UpToDate. https://www.uptodate.com/contents/approach-to-the-differential-diagnosis-of-leg-ulcers?search=arterial%20ulcer&source=search_result&selectedTitle=4~121&usage_type=default&display_rank=4.

11. Gonzalez, A. (2017). The Effect of a Patient Education Intervention on Knowledge and Venous Ulcer Recurrence: Results of a Prospective Intervention and Retrospective Analysis. Ostomy Wound Manage. 2017 Jun;63(6):16-28.

12. Crawford-Mechem, C. and Manaker, S. (2018). Hyperbaric oxygen therapy. UpToDate. Retrieved online at https://www.uptodate.com/error?search=hyperbaric%20oxygen%20and%20wound%20healing&usage_type=default&source=search_result&selectedTitle=2~150&display_rank=2.

13. Memar, MY, et al. (2018). Antimicrobial use of reactive oxygen therapy: current insights. Infect Drug Resist. 2018 Apr 24;11:567-576.

14. Medfocus guidebook on: Diabetic foot ulcers. (2011). Princeton, NJ: Medfocus.com, Inc.

15. American Diabetes Association. (2014). Foot complications. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/foot-complications/

16. Esposito, S., et al. (2018). New insights into classification, epidemiology and microbiology of SSTIs, including diabetic foot infections. Infez Med. 2018 Mar 1;26(1):3-14.

17. Cruciani, M., et al. (2013). Granulocyte-colony stimulating factors as adjunctive therapy for diabetic foot infections (review). Hoboken, NJ: John Wiley & Sons, Ltd.

18. Centers for Disease Control and Prevention (2017). National Diabetes Statistics Report. Diabetes Home. Retrieved from https://www.cdc.gov/diabetes/data/statistics/statistics-report.html.

19. Prabodha, LBL, Sirisena, ND, Dissanayake, VHW (2018). Susceptible and Prognostic Genetic Factors Associated with Diabetic Peripheral Neuropathy: A Comprehensive Literature Review. Int J Endocrinol. 2018; 2018: 8641942.


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20. Thewjitcharoen, Y., et al. (2018). Salient features and outcomes of Charcot foot - An often-overlooked diabetic complication: A 17-year-experience at a diabetic center in Bangkok. J Clin Transl Endocrinol. 2018 Jan 31;11:1-6.

21. Hordon, L.D. (2018). Diabetic neuropathic arthropathy. UpToDate. Retrieved online at https://www.uptodate.com/contents/diabetic-neuropathic-arthropathy?search=charcot%20foot&source=search_result&selectedTitle=1~36&usage_type=default&display_rank=1.

22. Stacey, M. (2018). Combined Topical Growth Factor and Protease Inhibitor in Chronic Wound Healing: Protocol for a Randomized Controlled Proof-of-Concept Study. JMIR Res Protoc. 2018 Apr 27;7(4):e97.

23. Treadwell, T. (2018). Comparative Effectiveness of a Bioengineered Living Cellular Construct and Cryopreserved Cadaveric Skin Allograft for the Treatment of Venous Leg Ulcers in a Real-World Setting. Adv Wound Care (New Rochelle). 2018 Mar 1;7(3):69-76.

24. Heredia-Juesas, J. (2018). Burn-injured tissue detection for debridement surgery through the combination of non-invasive optical imaging techniques. Biomed Opt Express. 2018 Mar 22;9(4):1809-1826.

25. Dincer, M., et al. (2018). An analysis of patients in palliative care with pressure injuries. Niger J Clin Pract. 2018 Apr;21(4):484-491.

26. Tennent, D., et al. (2018). Local control of polymicrobial infections via a dual antibiotic delivery system. J Orthop Surg Res. 2018 Mar 15;13(1):53.

27. Scalise, A., et al. Enzymatic debridement: is HA-collagenase the right synergy? Randomized double-blind controlled clinical trial in venous leg ulcers. Eur Rev Med Pharmacol Sci. 2017 Mar;21(6):1421-1431.

28. Legemate, CM, et al. (2018). Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial. Trials. 2018 Apr 19;19(1):239.

29. McCallon, SK, Weir, D, Lantis, JC (2015). Optimizing Wound Bed Preparation With Collagenase Enzymatic Debridement. J Am Coll Clin Wound Spec. 2015 Aug 15;6(1-2):14-23.

30. Li, W., et al (2017). Moist exposed burn ointment for treating pressure ulcers: A multicenter randomized controlled trial. Medicine (Baltimore). 2017 Jul;96(29):e7582.

31. Shih, AF, et al. (2018). Maggot therapy for calciphylaxis wound debridement complicated by bleeding. JAAD Case Rep. 2018 Apr 7;4(4):396-398.

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